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ARTICLE IN BRIEF

Neurologists are concerned that the immigration travel ban from seven Muslim-majority could have an impact on current and future training programs for physicians.

Regardless of the eventual legal fate of President Trump's Executive Order, or other efforts to bar immigrants and travelers from seven Muslim-majority countries, uncertainty is likely to continue for international medical graduates and other physicians considering coming to the United States, according to concerned neurologists.

On February 9, the United States Ninth Circuit Court of Appeals unanimously upheld a lower court decision that blocked further implementation of the January 27 Executive Order, but there are a number of options the White House can pursue to have the ban reinstated in some form, including challenging the new ruling before the Supreme Court.

However, just the fact that the ban was implemented at all will make students and others uneasy about coming to the US, said Tarif Bakdash, MD, FAAN, associate professor of pediatric neurology at the University of Mississippi University Hospital in Jackson.

“I think the damage has already been done, and I'm afraid that uncertainty is likely to linger for some time, even if there is a swift resolution to the issue,” he told Neurology Today.

Dr. Bakdash said the order has affected a humanitarian trip that he leads each year to Syrian refugee camps in Jordan. Some 50 physicians were supposed to accompany the Syrian-American neurologist in April. Given the uncertainty, he has canceled the trip for this year.

However, the greatest concern is about the potential impact that might keep foreign doctors from seeking training, research, or employment in the US, Dr. Bakdash said.

“Many foreign medical school graduates are likely to continue being afraid to come here for their training even if they are not from the countries currently on the list,” he said. “I know at least three other neurologists from the seven countries, and many of them are now fearful of leaving the US,” Dr. Bakdash said.

Saurabh R. Sinha, MD, PhD, vice-chair for education and director of the neurology residency program at Duke University Medical Center, agreed. He told Neurology Today that one of his residents from Pakistan is scheduled to return home to get married but is having second thoughts, even though Pakistan was not on the list.

“In the longer term, I think this controversy could have a chilling effect on how willing students from some countries will be to do their training in the US. I don't think that applicants will stop trying to come here, but some might have second thoughts about it,” he said. “It depends on how long this legal debate continues, and of course the Executive Order could be modified. But because it happened at all is likely to continue to cause uncertainty for neurology programs and students.”

ACADEMIC IMPACT

According to the American College of Physicians, 3,769 international medical graduates (IMGs) obtained first-year residency positions in 2016, and some 1,800 physicians from medical schools in the seven named countries are already in residency and fellowship programs in the US. Last year, 3,769 non-US citizen IMGs obtained first-year residency positions.

Dr. Sinha said the potential downstream effect of travel uncertainty on recruiting neurology residents and fellows is very troubling.

“Are we going to have all of our spots filled or not? How much risk are we willing to take? These are important questions for us, but right now we are up in the air,” said Dr. Sinha.

He noted that it is already difficult for graduates of foreign medical schools to get into the US, and that they often take low paying jobs for several years just to get into specialized training.

“We were a little worried about the President's rhetoric during the campaign, but most of us did not think it would affect those people we work with. I am especially worried about the impact on the H1-B visa program for temporary workers. A lot of fellows and residents have H1-B instead of J-1 exchange visitor visas because they did not expect this to become an issue.”

According to the Association of American Medical Colleges (AAMC), there are approximately 656,000 doctors and surgeons working in the US today, of which 254,000 are immigrants.

Data collected by a third party for the Medicus Firm, which recruits doctors for difficult-to-fill positions, indicate that about 15,000 physicians and surgeons come from the seven countries listed in the Executive Order, including 8,884 from Iran, 1,593 from Iraq, 3,423 from Syria, and 408 from Libya. Internationally trained IMGs represented 31 percent of physicians placed by the firm in 2016, and of these, 5 percent were placed in rural or midsized communities, including 12 percent who went to Wisconsin alone, said company spokeswoman Andrea Clement Santiago.

RESPONSE OF MEDICAL ASSOCIATIONS

Most major professional medical associations have addressed their opposition to the travel ban, individually and collectively, in letters to the Administration. Together with more than 60 other medical groups, the American Academy of Neurology (AAN) signed a February 1 letter to President Trump stating that efforts restricting the admission of certain foreign nationals and refugees will “disrupt patient care, health education, and medical research.”

The letter said that while it is important to safeguard national security, existing entry and renewal pathways for foreign nationals “provide a balanced approach that attracts the best and brightest from around the world and advances US interests through educational and cultural exchange.”

Any steps to make this more difficult “jeopardize critical access to health care for our nation's most vulnerable populations, including those in rural and urban underserved communities across the country,” the letter said.

Before the two courts stayed the ban, AAN's Executive Director and CEO Catherine M. Rydell told Neurology Today that the Academy is concerned about how the situation will impact education, research, and medical care.

“I wish I had a crystal ball. There could be unintended consequences, especially for foreign-born residents, especially with the National Resident Matching Program coming up [March 17].”

She also said the AAN is exploring alternative methods for researchers who may be affected by the immigration policy to present their scientific research at the AAN Annual Meeting, April 22-28 in Boston.

“Right now there are many uncertainties, and we have had a lot of questions from our board members. We are doing all we can to advocate because our membership is very concerned. We have to get the word out and have signed the letters, but at this point that is all we can do.”

In a February 1 letter to Secretary of Homeland Security John Kelly, American Medical Association CEO James Madara, MD, also pointed out the potential impact on IMGs.

“The Executive Order places into question those IMGs who have applied for or who have been granted visas to come to the United States to train and provide care in underserved communities,” he wrote.

“Guidance is urgently needed from the Administration to ensure the upcoming residency matching program on March 2017 does not leave training slots vacant and that all qualified IMG applicants can participate.”

Some of these physicians practice in underserved communities through the Conrad 30 Waiver Program that permits IMGs to remain in the United States after graduation in order to provide care to medically underserved communities.

Rafael H. Llinas, MD, FAAN, director of the department of neurology at Johns Hopkins Bayview Medical Center in Baltimore, also commented on how the current atmosphere could affect medical schools in the US.

“I think that what has happened is likely to affect our ability to recruit the best and brightest at our medical schools. It could mean they are more likely to consider schools in Europe instead,” he told Neurology Today.

“We had this happen after 9/11– a kind of travel ban although not this specific or broad. Until now things had become much better, but there are still a lot of international physicians not applying for residencies here,” he told Neurology Today.

“Really, many are unsure about their future here, but I have also heard that they feel uplifted by so many U.S. citizens who are protesting against any restrictions.” •

VISAS FOR INTERNATIONAL MEDICAL GRADUATES

J-1 Visa – A non-immigrant visa that permits IMGs to attend or participate in graduate medical school or training programs. Applicants must meet eligibility criteria and be sponsored by a university or government program, and can stay for seven years or as long as it typically takes to complete a program. After completing a program, physicians must return to their home country for two years before applying for readmission unless granted an H-1B waiver.

H-1B Visa – A non-immigrant visa for IMGs who are in clinical practice or engaged in graduate medical training, including residency, research, teaching, or patient care, and agree to stay in the US for a maximum of six years unless a special extension is granted.

Conrad 30 Waiver – Permits J-1 medical doctors to apply for a waiver of the two-year residence requirement after completing the J-1 exchange visitor program, in exchange for working full-time at a health care facility in a designated Health Professional Shortage Area (HPSA), Medically Underserved Area (MUA), or Medically Underserved Population (MUP) area. Each state also has special requirements, but an IMG must serve for a period of no less than three years after which he or she may apply for longer stays under other visa programs.